Multidisciplinary Management of Total Anterior Skull Base Osteoradionecrosis.

Cases of delayed osteoradionecrosis (ORN) of the anterior skull base have unique management considerations. A 59-year-old woman with a history of basaloid squamous cell carcinoma of the sinonasal cavity with intracranial extension through the anterior skull base developed delayed radiation sequelae of anterior skull base ORN. She underwent an initial endoscopic resection in 2011 with persistent disease that required an anterior craniofacial resection with left medial maxillectomy in 2012. She had a radiologic gross total resection with microscopic residual disease at the histologic margins prompting adjuvant chemoradiotherapy to target volume doses of 66 to 70 Gy with concurrent cisplatin chemotherapy. She subsequently developed an intracranial abscess in 2021 along the anterior skull base that required a craniotomy and endoscopic debridement. Despite aggressive surgical and medical therapy, she had persistent intracranial infections and evidence of skull base ORN. She ultimately underwent a combined open bifrontal craniotomy and endoscopic resection of the necrotic frontal bone and dura followed by an anterolateral thigh free flap reconstruction with titanium mesh cranioplasty. The patient recovered well from a microvascular free-tissue reconstruction without concern for cerebrospinal fluid leak. Anterior skull base reconstruction with free tissue transfer is a commonly utilized method for oncologic resections. Here, an anterolateral free flap was effectively used to treat an anterior skull base defect secondary to a rare indication of skull base ORN.

The impact of the pandemic on the presentation and treatment of head and neck squamous cell carcinoma at a county hospital.

INTRODUCTION: In March 2020, the World Health Organization declared COVID-19 a pandemic, initiating stay-at-home orders which delayed cancer care and screening. The impact on head and neck cancer care in populations at risk has yet to be elucidated. The objective of this investigation is to evaluate how the presentation, diagnosis, and treatment of head and neck squamous cell carcinoma cancer patients at a county hospital were affected by the pandemic. METHODS: A retrospective review of patients with head and neck squamous cell carcinoma that were diagnosed at a county hospital 365 days before and after stay-at-home orders were initiated. The primary outcomes were duration between diagnosis from imaging and initiation of treatment. Secondary outcomes included mortality, stage, nodal status, and distant metastasis at presentation. RESULTS: There was a total of 105 diagnoses. Sixty-five (62 %) head and neck squamous cell carcinoma diagnoses were diagnosed before the stay-at-home orders were initiated, and 40 (38 %) after. Eighty percent (32/40) of diagnoses presenting after had stage IV disease compared to 58 % (38/65) in those before (p < 0.05). A higher percentage of patients who presented later had a >30-day delay to biopsy (43 % v. 20 %, OR: 3.0, p < 0.05). This difference was exacerbated by those with laryngeal, oral cavity, or oropharyngeal cancer (45 % v. 15 %, OR: 4.5, p < 0.05). There was a larger delay from diagnosis to treatment after the orders were initiated (68 v. 53, p < 0.05) however there was no difference in one-year mortality (25 % v. 23 %, p > 0.05). This investigation found a 14 % loss to follow-up. CONCLUSIONS AND RELEVANCE: In this cohort of head and neck squamous cell carcinoma diagnoses at a county hospital, those diagnosed after the stay-at-home orders were initiated presented with more advanced disease. They also had more delays in diagnosis and initiation of treatment. There was no difference in one-year mortality rates between the two groups however there was a significant loss to follow-up, limiting prognostication. These findings serve to better prepare healthcare providers to implement optimized care during future shutdowns related to public health crises. LEVEL OF EVIDENCE: III.

Traumatic xylophagia leading to foreign body removal and tracheostomy in the setting of postpartum psychosis.

Postpartum psychosis (PPP) is a severe mood disorder following childbirth that rarely leads to injurious or suicidal behavior. This report illustrates otolaryngologic intervention for pharyngeal laceration and airway instability following traumatic foreign body ingestion in the setting of PPP. A 25-year-old woman with PPP presented with hemoptysis after attempting suicide by traumatically forcing tree branches into her oropharynx. Imaging revealed pneumomediastinum, and flexible laryngoscopy and esophagoscopy showed a large foreign body (tree branch) extending from the hypopharynx to the gastroesophageal junction. She was taken to the operating room for direct microlaryngoscopy, bronchoscopy and esophagoscopy with removal of the 25-cm tree branch. Panendoscopy revealed a mucosal laceration at the cricopharyngeus with supraglottic and hypopharyngeal edema but no injury to the larynx. Due to airway concerns, a cuffed tracheostomy was placed along with a gastrostomy tube for feeding access. She tolerated her postoperative course with successful decannulation and oral feeding prior to discharge.

Intracranial Meningioma Surgery: Value-Based Care Determinants in New York State, 1995-2015.

OBJECTIVE: Intracranial meningiomas are the most commonly diagnosed brain tumor in the United States. With increasing incidence, efficient allocation of limited health care resources is a critical component of emerging value-based models of care. The purpose of this study was to evaluate the effect of patient and hospital variables on metrics of value-based care. METHODS: The Statewide Planning and Research Cooperative System database was queried for records of patients undergoing intracranial meningioma surgery in New York State from 1995 to 2015. Multivariate logistic regression was used to investigate the effect of hospital volume and patient demographics on 30-day readmissions, 30-day mortality, prolonged length of stay (pLOS), and excess hospital charges. RESULTS: Among the 14,239 patients included, 10,252 (72%) cases were performed at high-volume centers (HVC) (>75th percentile). HVC were associated with lower rates of readmissions, mortality, and pLOS, but higher hospital charges. In the multivariate analysis, HVC had reduced odds of pLOS (odds ratio, 0.56; P < 0.0001) and 30-day mortality (odds ratio, 0.39; P < 0.0001). Patient variables associated with adverse outcomes in the multivariate model included advanced age, male gender, higher Charlson Comorbidity Index, lower socioeconomic status (low income, Medicaid, and Medicare insurance), black race, and Hispanic ethnicity. These populations were more likely to undergo treatment at lower-volume centers. CONCLUSIONS: This statewide population analysis of readmissions, mortality, length of stay, and hospital charges after intracranial meningioma surgery identified patient predictors of adverse outcomes. These determinants may be used by hospitals to develop improved systems of care in at-risk populations.

Potent HIV-1 Protease Inhibitors: Stereoselective Synthesis of a Dipeptide Mimic.

The synthesis of a differentially protected dipeptide mimic 10 in enantiomerically pure form is described. The key step involves the epimerization of the C-2 center of the lactone 4, hydrolysis and protection of the resulting hydroxy acid, followed by Curtius rearrangement to introduce the urethane functionality. The scope and versatility of this isostere has been demonstrated by its conversion to potent HIV-1 protease inhibitors with nanomolar potencies. Also, established through the synthesis of compound 13 and 14, the 3S hydroxyl configuration of the dipeptide isostere 1 is the preferred configuration for its potency. The present synthesis is efficient and provides an access to other dipeptide mimics with a great deal of structural diversity.

An Efficient Synthesis of Functionalized Urethanes from Azides.

Catalytic hydrogenation of various azides in the presence of functionalized mixed carbonates afforded the corresponding urethanes in high yields.

N,N'-Disuccinimidyl Carbonate: A Useful Reagent for Alkoxycarbonylation of Amines.

An efficient and mild method for alkoxycarbonylation of amines is described, utilizing commercially available N,N'-disuccinimidyl carbonate.

A Facile and Enantiospecific Synthesis of 2(S)- and 2(R)-[1'(S)-Azido-2-phenylethyl]oxirane.

The title azidoalkyl oxiranes were synthesized efficiently in an enantiomerically pure form utilizing readily available diethyl d-tartrate.

Highly Enantioselective Aldol Reaction: Development of a New Chiral Auxiliary from cis-1-Amino-2-hydroxyindan.

Boron enolates obtained from optically active oxazolidinone derivative of cis-1-amino-2-hydroxyindan are reacted with various aldehydes to provide highly enantioselective aldol products in good yields.

STEREOCONTROLLED SYNTHESIS OF HIV-l PROTEASE INHIBITORS WITH C2-AXIS OF SYMMETRY.

An efficient and stereocontrolled synthesis of various C2-symmetric HIV-l protease inhibitors is described, starting from commercially available and inexpensive D-mannitol.

STEREOSELECTIVE REDUCTION OF α-HYDROXY OXIME ETHERS: A CONVENIENT ROUTE TO CIS-1,2-AMINO ALCOHOLS.

Reduction of cyclic α-hydroxyketoximes with borane provides an excellent, high yielding, regio- and stereoselective route to CIS-1, 2-amlnoalcohols.

An Efficient Synthesis of Hydroxyethylene Dipeptide Isosteres: The Core Unit of Potent HIV-1 Protease Inhibitors.

An efficient and stereocontrolled synthesis of hydroxyethylene dipeptide isosteres 1 from commercially available, optically pure D-mannose is described. This synthesis represents a practical and enantioselective entry to a range of other dipeptide isosteres, which are not limited to amino acid derived substituents.

Di(2-Pyridyl) Carbonate Promoted Alkoxycarbonylation of Amines: A Convenient Synthesis of Functionalized Carbamates.

The reaction of di(2-pyridyl) carbonate with a variety of alcohols including hindered secondary, tertiary and protected glycols afforded the corresponding mixed carbonate which was efficiently transformed into various carbamates in high yield under mild conditions.